NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. The wife of a client who is dying says, 'I want to see him, but I can only come twice a week because of work, household chores, and caring for our cat and dog.' Which defense mechanism is the wife using?
- A. Projection
- B. Sublimation
- C. Compensation
- D. Rationalization
Correct answer: D
Rationale: The wife is using rationalization as a defense mechanism. Rationalization involves offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. In this scenario, the wife justifies her limited visits to her dying husband by citing other responsibilities such as work, household chores, and pet care. Projection involves denying one's unacceptable feelings and attributing them to others. Sublimation is the substitution of unacceptable feelings or drives with socially acceptable behaviors. Compensation involves making up for a perceived deficiency by emphasizing another perceived asset.
2. Which assessment data would be most important to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values?
- A. Dietary practices
- B. Concept of space
- C. Immigration status
- D. Role within the family
Correct answer: D
Rationale: The most important assessment data to obtain from an Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values is their role within the family. In traditional Asian cultures, the family holds significant importance and plays a central role in influencing an individual's well-being. Understanding the client's role within the family can provide crucial insights into their support system, stressors, and coping mechanisms. Dietary practices, concept of space, and immigration status, while potentially relevant, are not as vital in this context compared to understanding the dynamics and influence of the family structure on the individual's mental health.
3. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?
- A. "I'm huge; I'm as big as a house."
- B. "I get straight A's in all my subjects."
- C. "My mother keeps trying to get me to eat."
- D. "My hair is beginning to fall out in clumps."
Correct answer: C
Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A's in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.
4. A man who is admitted for a suicide attempt after the death of his child says, 'I hear my son telling me to come over to the other side.' Which psychotic symptom is the client experiencing?
- A. Fixed delusion
- B. Magical thinking
- C. Pathological regression
- D. Command hallucination
Correct answer: D
Rationale: The client is experiencing a command hallucination. Command hallucinations involve auditory messages instructing harm to self or others, and giving an identity to the hallucinated voice increases the risk of compliance. A fixed delusion is a false belief held to be true despite evidence to the contrary. Magical thinking involves believing that thoughts can influence events, commonly seen in young children. Pathological regression refers to reverting to a previous developmental stage, not applicable in this scenario.
5. Which nursing action promotes psychosocial development for a newborn?
- A. Washing hands before holding the newborn
- B. Measuring the newborn using an approved length board
- C. Weighing the newborn on the same scale during hospitalization
- D. Placing the newborn in the mother's arms during the first hour of life
Correct answer: D
Rationale: Placing the newborn in the mother's arms during the first hour of life is a crucial nursing action that promotes psychosocial development by fostering bonding between the newborn and the mother. This skin-to-skin contact enhances emotional attachment, facilitates breastfeeding initiation, and provides a sense of security for the newborn. It helps in regulating the newborn's temperature, heart rate, and breathing, promoting overall well-being. Washing hands before holding the newborn is essential for infection prevention and control to maintain the newborn's health and safety. Measuring the newborn using an approved length board and weighing the newborn on the same scale during hospitalization are assessments aimed at monitoring the newborn's physical growth and development, rather than directly promoting psychosocial well-being.
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